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AMENTIA IN MEDICAL DIAGNOSIS"

B Y G E O R G E ' V A N N E S S D E A R B O R N ' , M. D., P H . D ,


U N I T E D STATES VETERANS ~ FACILITY~ T H E BRONX 3 N E W YORK C I T Y

Although a matter of wide disagreement, human intelligence


seems to be best considered as the ability of the personality to
learn through its more or less conscious experience. Feebleminded-
ness or aluentia (as it is more scientifically termed) is some degree
of the lack of this ability. It is my present object to recount some
of the reasons why the art of medicine should take into considera-
tion the intelligence of its patients, and how accurate diagnosis in
particular depends oftentimes on a knowledge of the patient's rela-
tive intellectual level. Physicians not infrequently are misled by
disregard of this knowledge.
Intelligence being at least somewhat as we have indicated, amen-
tia involves the working of all of the sensitive organism and of all
of the personality. In general, then, in proportion to the subjec-
tivity of an examination the patient's intelligence is important.
Even a lump in one's abdomen or a broken femur has some sub-
jective factors of use to an adequate surgeon. It is only when we
begin to realize how much the concept intelligence includes that
we can appreciate how far-reaching are the effects of its relative
lack in the personality.
In case-histoiT taking, to begin with, it is plain that the ament
is going to mislead the physician more or less as compared with
the normal patient, being less accurate, shorter-memoried, less
appreciative of illness and of former symptoms, less systematic,
and so on. The examiner should be in a mental position to allow
for these considerations if he wishes to have adequate backgrounds
for his examinations. Family relationships are ill-appreciated by
the feebleminded and family history is certain to suffer in conse-
quence.
But the situation is much worse in regard to immediate diagnos-
ing. The reasons for this will be more readily accepted if we
briefly recall to their minds some of the elementary pure psycho1-
*Read before the fifty-eighth annual meeting of the American Association on Mental Deficiency
.in New York on May 26, 1934.
It is published with the permission of the medical director of the Veterans' Administration, who
assumes no responsibility for the opinions expressed or the conclusions drawn by the writer.
526 AI~IENTIA I N lYIEDICAL DIAGNOSIS

ogy of amentia--a topic, by the way, on which there is not too


much literature. In the most general way this psychology is that
of primitive man which in turn is that of the savages of our day
and in part at least that of our young children, but with importan t
differences.
The senses of aments undoubtedly are somewhat less efficient
than are those of average folk. The tactile and the pain-senses
are less acute; on this rests part at least of the lessened sensory
discrimination often conspicuous in the feebleminded. In general
the sensory threshold is high, but part of this practical difference
is due to the inherent concreteness of their mentation. For exam-
ple in the familiar Dutch-kitchen picture of the Binet-Terman
scale the low morons point out the objects but fail to note that it is
a view of a little girl crying. They fail to get the abstract con-
cepts which are the associative product of percepts. By a like
lack of mental integration aments have poor judgment and weak
understanding, the succeeding steps of association. For this same
basal reason they may fail relatively to understand what is said to
them; and because of the very close interdependence of ideation,
intelligence, and language, they tend to inadequate expression of
even what they do think and understand. Their mentation is slow
and this mere delay in feeling, in thinking, and in answering, blocks
intercourse and accuracy more than most folk realize.
Now these defects in the constructive intellectual process of
aments, and others less important, bring it about that these people
know much less about their bodies and their minds, about physiol-
ogy and hygiene, prophylaxis, the symptoms of disease and the dis-
eases themselves than do those of normal intelligence. This rela-
tive ignorance and ill-appreciation is the inevitable consequence of
the limitation of associative integration, of the relative lack of plan-
ning and of unifying understanding that is the ament's most impor-
tant mental lack. He realizes less well than do most that he is an
unified personality, that his organs work together to make him a
living organism in the closest relation with his environment, and so
on. Such appreciation in itself is a vague gauge of one's intelli-
gence for all who never have studied biology in its widest sense.
Aments do poorly in this unstandardized test of life-wisdom sub-
GEORGE VAN NESS DEARBORN~ M. D.~ P I t . D. 527

consciously acquired; and they have little idea of hygiene usually,


especially of mental hygiene.
In this place we should speak of one mental lack that is particu-
larly important for diagnosis, namely, a relative general analgesia.
I have long been a student of this subject pain, and I am convinced
that, as a rule, both pain and unpleasantness are felt very roughly
in proportion to the personal intelligence, especially when this is
used, as nmstly it may be used, as an index of affective intelligence
also. Of course some are more intelligent on the feeling-aspect of
mind and some in the purely intellectual aspect, but ~'in the large,''
on the average feeling and intellect mutually correspond in the
individual and that often in a high degree of correlation. In men-
tal deterioration the two usually lower together, and in amentia
both frequently are deficient. This applies mostly to unpleasant-
ness which is entirely distinct from true pain, a sensation, pure
and relatively simple. But there is the best of biological reason
to believe that pain itself, as well as its affective interpretation and
reaction, is less keenly felt in aments than in normal persons. Pope,
a keen analyst of human nature says, " N o creature smarts so little
as a fool."
The importance of this circumstance in diagnosis he who runs
may realize, for the purpose of pain certainly is to warn of im-
-pending harm--an abstraction, we may note in passing, that the
oligophrenics, as Bleuler terms them, are not apt to realize as ef-
fectively as do others. So that pain becomes of a double import-
ance in our argument.
In the same category sundry other general warnings are apt to
be ignored or undervaluated by aments, notably chills; dyspnea;
certain coughs; headaches; weakness; habitual emesis; real asthe-
nia; progressive and unexplained loss of weight, to say nothing of
aprosexia, failing memory, "voices," suspicions, depression, and
phobias. Such disease-signs as these, the marons do not appreciate
fully, and this fact is very apt to be ignored by the diagnostician,
and that even when he realizes that the patient is intellectually
deficient.
528 A M E N T I A I N MEDICAL DIAGNOSIS

In the following paragraphs we point out a few samples of the


commoner medical, surgical, and sociologic conditions in which
allowance for amentia is of especial importance in diagnosing.
These pretend to be little more than examples of the kinds of cir-
cumstances under discussion.
Acute fevers with not too high pyrexia may well head the list.
The ament does not realize he is ill as soon and as clearly as would
a person of normal intellect, because he does not abstract well
enough to discriminate his ill condition. In this he is like young
normal children.
In like manner, acute painful inflammations: pleurisy, pneumo-
nias, appendicitis, pyelitis, enteritis, phlebitis, neuritis, owing to
pain-considerations already suggested, are apt not to be denoted
and described even as well as by the average patient, nor appreci-
ated as soon.
Visual disturbances of many kinds are liable to be unreported
longer than by normals, and deafness and sore throats.
Contagious diseases are of especial danger in amentic families
for obvious reasons.
Skin diseases may be taken for granted as ordinary or even nor-
mal, especially those of parasitic etiology.
Pulmonary tuberculosis is especially fatal among aments; thou-
sands have died of it who would have been cured with personal in-
telligence in control.
Pregnant " g i r l s " and women fail to appreciate the necessity of
medical care and often suffer serious consequences.
Venereal disease is not evaluated by the feebleminded as it is by
normals, with frequent disastrous results from both of the major
infections. Prostitutes are frequently intellectually defective by
reason of under-inhibition and under-self-control, as well as from
lack of foresight and plan.
And there are the numerous chronic nervous diseases; in these
subjective analysis and appreciation are of very great diagnostic
importance, and the average cooperation cannot be expected from
aments. Some of my possible readers would be surprised perhaps
to know how frequently even the neuropsychiatrists fail to realize
that their patients are feebleminded. For example, epilepsy is in
GEORGE VAN N E S S DEARBORNt M. D. 3 P H . D. 529

some yet unknown way frequently related to amentia; and more-


over most epileptics deteriorate intellectually sooner or later. In
regard to this category as in others physicians frequently ignore
the obvious fact that the mentally defective are just as likely as the
intellectually normal to have chronic cord diseases such as multiple
sclerosis, etc.
Even in purely surgical conditions, with their minima of sub-
jective factors, preliminary intellectual diagnosis is important in
nosology as it is in treatment, that due allowance may be made for
reaction-differences of various kinds.
In the diseases whose etiology partly is dissipation (with alco-
hol, venery, nicotin and its congeners, caffein, narcotics, etc., etc.)
amentia plays frequently a very important part, both in the per-
sonal habituation and in its diagnosis. Hygiene is vague to the
defectives and the devastating efforts of these means of dissipa-
tion are mostly unrealized or unknown. How could a physician ex-
pect to have adequate history, symptomatology, or cooperation
from morons in these circumstances ?
As a matter of course, from the abstract nature of the disabili-
ties, it is most important that the exmnining physician should real-
ize fhe mental deficiency of patients with psychiatric disorders,
especially those with the psychoneuroses. But all psychiatric con-
ditions, psychoses, and psychoneuroses, greatly overlap in the pres-
ent system of diagnosis. Under such circumstances one need not
argue that the aments with psychoneuroses or with psychoses are
especially difficult to place in a nosologic group. ~Vhen the symp-
toms or attacks are mild or borderline or otherwise in doubt, amen-
tia "makes all the difference in the world." In hospitals one sees
so many cases of multiple tentative diagnoses on which the exam-
iners cannot agree solved in an hour by a psychological examina-
tion and to the satisfaction of all! Here is one answer to the
ancient question of the poet, for frequently it is the psychologist
"who shall decide when doctors disagree."
But in psychiatry in general diagnosis is greatly handicapped by
subnormality of the patient's intelligence. Such terms and con-
cepts as memory, interest, attention-control, sensation, dizziness,
being abstractions, are not clearly understood or differentiated, so
530 A M E N T I A I N MEDICAL DIAGNOSIS

that the patients have only vague ideas of what you wish them to
tell you. Hallucinations are hard to explain to them, and autistic
thoughts, and phobias, dreams, conflicts, orientation--in short,
dozens of abstract psychiatric concepts not clearly understood or
recognized in relation to any experience they have had. Time is
vague to the aments as it is to young children, giving rise some-
times to misunderstandings. Cause and occasion (post hoc ergo
propter hoc) are confused even more regularly than by normal but
thoughtless people. Family relationships are ill-appreciated. Very
important, and to a degree actually pathognomomic of amentia,
is the typically feeble appreciation of likeness and unlikeness, and
of change of any kind ; as is well realized, judgment of dissimilarity
is t h e one basal intellectual process of mind. Thus the feeble-
minded .do not know that they have become neurotic or psychotic
when folk of normal intelligence often would recognize their condi-
tion. This blindness to change effects diagnosis of every sort, but
that of mental disorder naturally more than others.
Amentia itself in its various well-defined 15 degrees or so is a
diagnosis, and in hospitals at any rate, when present, should always
be added to the diagnostic list as a matter of scientific accuracy as
well as for the benefit of future examiners. The day is all but
passed when it is looked upon as a "disgrace," because now it is
seen to be either purely an accident or else a mental deformity,
congenital or "near-congenital," for which no person is to be
blamed any more than a mother is to be reproached (killed, in some
savage society l) for giving birth to a monstrosity of the somatic
kind.
Oligophrenics, i. e., the feebleminded, are easy game for c e r t a i n
types of hunter, namely those hunting for easy livings--the healers,
the quacks, chiropractors, and such--because from lifetime habit
the aments have been subject to continual suggestion, instruction,
meticulous guidance from without rather than from within their
own cytopenic cortices, their inner understanding of things and
guidance by themselves necessarily failing. They tend to believe
what is told them, to buy "gold bricks" hopefully and with satis-
faction. They buy patent medicine extravagantly and appliances
GEORGE VAN NESS DEARBORN~ M. D.~ F H . D. 531

and devices even more expectantly than the proletariat--which is


saying much indeed.
Self-preservation in general is apt to be far less effectively car-
ried on by a defective because of his less appreciation of the dan-
gers, sundry perilous conditions inside and outside his organism.
For example, few of these people realize the serious import of epi-
leptic seizures. Aments who are unwittingly allowed to drive
motor cars, e. g., are a serious menace to others and to themselves
because of their long reaction-times, their slow and inadequate
thought, their comparative ignorance of the regulations, etc. Owing
to the lack of intelligence tests before the licensing of drivers, no
one knows how many of the myriad auto-accidents are due to the
feeblemindedness of drivers. Here is an example of the prime
urgent importance of amentic diagnosis in matters of social welfare
somewhat outside of medical matters proper. And there are
others !

So much for some of the obvious sanctions of learning and of


making allowance for amentia so that diagnosis may be more accu-
rate and more reliable in medicine.
A few considerations now are both relevant and fully competent
as to why patients' intelligence is not more commonly inquired into
by examining physicians. Quite a good many really intelligent
physicians have failed even yet to receive the new psychometric
light, and this failure is not wholly due to a feeling of their own
adequacy, a feeling not entirely unheard of in the profession.
Among these physicians there are even some psychiatrists, strange
as it may seem. Some are uninformed, some misinformed, and
some undeniably are prejudiced against intelligence measurement
both in aments and in deteriorates or dements. This somewhat
unfortunate state of things certainly is due in part to a mental
overhang, so to say, from the exaggerated claims of early
" t e s t e r s " before this popular phase of applied psychology had had
time to standardize itself, its methods, and its results.
When one attempts to explain why many physicians retain this
prejudice against almost anything psychological, including psycho-
metry, one must turn to the two outstanding age-long familiar rea-
532 A M E N T I A I N MEDICAL DIAGNOSIS

sons: First, the old traditional reactionary thoughtless material-


ism of medicine. Second, their ignorance of modern psychology
theoretic and applied. Both of these, fortunately for medicine, are
now in the way of being overcome, as it grows more and more obvi-
ous to the "social consciousness" that psychology is the basal sci-
ence of the whole hierarchy of scientific "disciplines;" that mind
and not body is the dominant and significant aspect of the individ-
ual, our nomistic locus of life.
No one quite so well as the psychologist (the psychiatrist is an
"abnormal psychologist") knows how recondite, intricate, intangi-
ble and subtle is the human mind--an all-important personal mys-
tery. It is such a thing as a priori one might reasonably expect
could not be measured by any relatively simple "yard-stick" any
more than the wisdom of a judge, the intelligent happiness of true
love, the skill of an author, the beauty of a Nova Scotian sunset,
or the misery of an only son's .demise. So that no one ever had any
reason to believe that human mentality could be measured accu-
rately by a scale. Personally I know no such person anywhere,
either at present or formerly when measuring was new.
For medical work it is essential that the psychologist, especially
if he is to do measuring for psychiatrists, should have in mind the
rudiments of modern psychiatry. This is particularly true for that
new branch of psychometry that is concerned with the determina-
tion and the rough but adequate measurement of intellectual dete-
rioration, dementia. For practical jurisprudence and nosologic
psychiatry this part of intelligence-determination often is quite as
important and productive as the measurement of native defect, but
with it the present paper has little specific concern.
In this presentation it is quite inexpedient to comply with the
classic canon of the scientific method by which not opinions but only
facts, actual or apparent, are to be given out in a scientific report.
But I am assuring my readers that facts in great number underlie
the opinions herein set forth.
As an example of the progress of psychological examining ("psy-
chometry") I beg to present, in closing, a list of the considerations
that are to be taken into account, pro tanto and so far as is prac-
ticable, in every intelligence-examination, but especially of adults.
GEORGE VAN IqESS DEARBORlq~ iV[. D.~ P H . D. 533

The reasons for including all of these two dozen factors of an ade-
quate intelligence-examination would require an article--and you
escape it. But after all the main thing is to have them down in
black and white as a refutation that an intelligence test is arbi-
trarily and falsely mechanical. These are all factors in the opinion
as to a person's intelligence and have been so used by me for sev-
eral years in so far as has been expedient or possible in each case.
Here they are :
1. The schooling had by direct-line ancestors. 2. Ages of walk-
ing, talking and reading, when available. 3. Age of the beginning
of schooling, when available. 4. Public or private schools attended.
5. Rural or urban schools ; geographic location, (country). 6. Num-
ber of months in a school year. 7. Grade attained at what age. 8.
Reason for leaving school, (the real reason). 9. Number of times
" l e f t back" (or " j u m p e d " ) and why. 10. Comparison of "smart-
n e s s " with that of his siblings, especially in school. 11. General
mental reaction-time adjusted by the " t y p e " of mentation. 12.
Relative success in arithmetic in school. 13. Reading-ability and
reading-habits. 14. Occupation in general, involving the intellect-
ual grade of the work. 15. Maximum .regular earnings under usual
conditions. 16. If foreign-born, length of time and efficiency in
acquiring English. 17. His own opinion of the relative intelligence.
18. Opinion of his immediate family as to his relative intelligence_,
if available. 19. Binet-Terman questions (VII, 5; VIII, 4; XII, 8;
XIV, 3; XVI, 3) on likeness and unlikeness (in suspected deteriora~
tion). 20. Has fixation of attention been difficult of late? (in sus-
pected deterioration). 21. Have memory and recall been failing of
late? (in suspected deterioration). 22. Re-examination on another
day by the same method (unless it be a performance test). 23.
Intensive method of examination, while keeping the subject's sthe-
neuphoric index high. 24. The studied and intensive use of a com-
pletely standardized and long-used intelligence-scale, preferably
when not contra-indicated, the Binet-Terman (Stanford).
One gets most of this material in a very casual and easy way,
with the expenditure of little time and effort, in so far as it is ob-
tainable at all. Plainly does it mean an intelligence-examination of
534 A M E N T I A I N MEDICAL DIAGNOSIS

the person's entire individuality. " W h a t further could be sought


for or declared ?"
And so do we revert to the thesis of this modest presentation,
namely, that it is important for accurate diagnosis in the art and
science of medicine that due consideration should be given to the
intelligence-status of the patient.